Research Article
Pharmacists’ Roles in Post-September 11th Disasters: A Content Analysis of Pharmacy Literature
Journal of Pharmacy Practice 2014, Vol. 27(4) 350-357 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190013507081 jpp.sagepub.com
Heath Ford, PharmD, PhD, CGP1, Trina von Waldner, PharmD2, and Matthew Perri III, RPh, PhD3
Abstract Purpose: To characterize the roles pharmacists have assumed in disasters and clarify the types of roles and disasters that may be less well-documented in the pharmacy literature. Methods: This research examines how balanced or equally proportioned role categories are in the pharmacy literature, whether pharmacy journals differ in the proportion of role categories reported, and whether journals significantly differ in the proportion of reported chemical, biological, radiological, nuclear (CBRN), and natural disasters. Data coding was performed solely by the lead author using Concordance (Harvard University, Cambridge, Massachusetts), a Web-based content analysis software, and Minitab1 (version 15; Minitab, Inc; State College, Pennsylvania) for descriptive and inferential statistical analysis. Pharmacy journals publishing at least 2 articles about pharmacist disaster roles from September 11, 2001 to September 30, 2011 were used in the study and were available electronically. Results: Chi-square analyses reveal significant differences in the weighted counts of roles, roles categorized by journal, and CBRN disasters categorized by journal. Conclusions: Data suggest that pharmacists may be prepared to respond to hurricanes and biological and chemical disasters in pharmaceutical supply and patient management roles. Future research should highlight efforts to prepare health systems for the effects of nuclear, radiological, and chemical disasters. Keywords disaster management, disaster preparedness, natural disasters, terrorism, pharmacist roles
Introduction and Purpose Statement The role of the pharmacist in disaster preparedness and response has become increasingly important since the terrorist attacks on the World Trade Center and Pentagon. Pharmacists have traditionally managed the nation’s drug supply by dispensing prescription medications to patients presenting with a physician’s order, but while this role continues as the mainstay of most pharmacy practices, pharmacists’ skills have developed well beyond those traditionally described.1 With the advent of the pharmaceutical care paradigm introduced by Hepler and Strand in the early 1990s, pharmacists have assumed more patient-oriented roles in their daily activities, moving beyond traditional dispensing duties and actively assuming the responsibilities of a primary care provider.2 Some of these activities include counseling patients regarding medication use, managing oral and intravenous medications, consulting with prescribers regarding optimal pharmacotherapy and parenteral nutrition, and monitoring patients for drug-related problems. Practice activities have embraced the ideals of ensuring proper use of medications and mitigating human suffering. Austin and colleagues, for example, note that in times of crisis, local pharmacies become crucial to maintaining public health care services, and pharmacists, the health professional group
most accessible to the public, assume responsibilities beyond their traditional scope of practice.3 Previous research articles, including Braucher’s description of pharmacist roles in relief efforts after a simulated nuclear detonation, are particularly relevant to a post-September 11th era and certify the importance of pharmacist participation in disaster preparedness and response, especially when few health care providers are expected to survive the initial events.4 Disaster preparedness and response are specific domains in which pharmacists can provide valuable expertise to improve patient outcomes and promote appropriate medication use.
1 Department of Pharmacy Practice, South College School of Pharmacy, Knoxville, TN, USA 2 Division of Nontraditional Education and Outreach, University of Georgia College of Pharmacy, Athens, GA, USA 3 Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
Corresponding Author: Heath Ford, Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 231 R.C. Wilson Pharmacy Building, Athens, GA 30602, USA. Email: [email protected]
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Although resource-depleting disasters present scenarios where pharmacists assume tasks traditionally belonging to other disciplines, these scenarios have not been sufficiently elucidated in the literature.3 Multiple reports describe the utility of traditional and expanded activities of pharmacy practice in a variety of natural and man-made disasters, with the pool of published articles continuing to increase.5-48 As Cohen notes, however, little attention has been given to characterizing the roles of pharmacists in disasters although the importance of pharmacists’ involvement is widely acknowledged.5 In fact, no report to date has been published that both characterizes the roles pharmacists have assumed in disasters and clarifies the types of roles that may be less well-documented in the pharmacy literature. Consequently, various roles may be understated, pharmacy response to disasters may be less well developed, and the capability of terrorists to do harm may ultimately be increased. When considering the reports describing how pharmacists have responded to disasters, questions arise: which roles and disasters have the most literature support and do journals show tendencies in reporting particular roles and disasters? One would assume that traditional, routine roles such as dispensing medications and counseling patients would be 2 that should be well developed in the pharmacy literature, but patient-centered, hands-on functions such as providing direct aid to casualties at the site of disaster may not be as proportionately represented. Journals may also significantly record more of specific types of pharmacy roles. For example, the American Pharmacists Association is a major advocate of pharmacists as immunization providers and devotes a portion of their journal and professional Web site to help pharmacists attain certification and maintain immunization practice standards. It is not clear, however, whether the Journal of the American Pharmacists Association reports immunization practices as a disaster response function more than other pharmacy journals. Similarly, the American Journal of Health-System Pharmacy may also limit their reports of role descriptions to those that would most likely interest hospital pharmacists (eg, developing medication guides, managing emergency formularies, providing poison information services, etc). Pharmacy journals may show tendencies in reporting particular disaster preparedness and response functions and thus perceive certain events as more relevant than others. This could unexpectedly present unique challenges to the provision of pharmacy services if certain disasters are not adequately addressed in the literature. Chemical, biological, radiological, nuclear (CBRN) and natural disasters reported in pharmacy literature may also be unequally proportioned. For example, widespread disasters caused by detonation of a small nuclear device, widespread bioterrorism, collapse of multiple city skyscrapers, or due to natural causes may not be proportionately recorded in the literature and thus represent areas of pharmacy preparedness that are inadequately developed. Thus, the purpose of this research is to describe pharmacists’ disaster preparedness and response roles according to published reports in pharmacy literature and to clarify the types of disasters that have been reported. To this end, 3 primary
questions will be addressed. (1) How balanced or equally proportioned are role categories in the pharmacy literature? (2) Do journals significantly differ in the proportion of role categories reported? (3) Do journals significantly differ in the proportion of reported natural and CBRN disasters?
Methods Role Categorization Pharmacists’ roles in disasters have been categorized in at least 3 reports in the pharmacy literature.6-8 Pincock and colleagues present a disaster-readiness model to better prepare pharmacists and disasters planners for future contingencies. A second categorization elucidated by Chin and colleagues is noteworthy for the identification of 5 categories of pharmacy functions: drug information, direct patient care, pharmacy operations, collaboration and communication, and personnel management. However, in terms of characterizing and explaining pharmacists’ roles in disasters, perhaps the most carefully defined categorization of pharmacists’ functions is set forth by Setlak who identifies 4 main types: response integration, patient management, pharmaceutical supply, and policy coordination. Response integration describes pharmacists integrating into the casualty response by triaging patients alongside physicians and nurses and administering first aid and cardiopulmonary resuscitation (CPR) as experience and training allow. Patient management, the second category, involves patient-centered approaches to managing medication therapy outcomes. Pharmaceutical supply, the third category, describes the logistics of providing medications to large numbers of patients, and the last category describes the need for pharmacists to help coordinate disaster policy to eliminate duplicate therapies in emergency formularies, streamline paperwork to avoid duplicative forms, and generally apply drug expertise in decision making.7 This article organizes the broad array of pharmacy literature reports of pharmacists’ disaster functions according to the Setlak categorization.
Disasters in the Pharmacy Literature Numerous references to disasters have appeared in the pharmacy literature since as early as the 1960s. Two classifications—natural disasters and terrorism—will be used to classify disaster types. Table 1 describes the disaster classification scheme used in this analysis. Natural disasters may include tornadoes, fires, earthquakes, floods, or any man-made accident. Terrorism includes CBRN terrorism or use of any ‘‘violent or threatening means to intimidate or coerce, especially for political purposes.’’9 Table 2 displays the chronologic order of the disasters with journal articles that give reference. The disaster genre of pharmacy literature beginning in the early 1960s to the 1980s exclusively reflects responses to natural disasters. The 1980s begin to reference terrorism, with the quantity of literature citations growing substantially in the 1990s. Although the 2000s are dominated primarily by articles citing natural disasters, the
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Table 1. Disaster Classification Scheme. Natural Disasters Tornadoes Fires Earthquakes Floods Hurricanes Storms (rainstorms, windstorms, tropical storms, and snowstorms) Manmade accidentsa (train, car, and plane crashes) CBRN disasters (including terrorism) Chemical (any chemical agent as well as bombs, explosions, and explosives) Biological (any biologic agent as well as pandemic influenza) Radiological (including ‘‘dirty bombs’’) Nuclear Abbreviation: CBRN, chemical, biological, radiological, nuclear. a Excludes CBRN disasters.
2 main acts of terrorism frequently referenced by articles in the pharmacy literature are the September 11, 2001 attacks on the World Trade Center and Pentagon as well as the October 2001 anthrax attacks in Washington, District of Columbia, Florida, New Jersey, and New York. Particularly noteworthy is the prevalence of terrorism reports from 1993 to 2001, with natural disasters dominating literature before and after this period.
elucidated from an analysis of peer-reviewed pharmacy publications. As such, peer-reviewed pharmacy journals used in the study were available electronically and published at least 2 articles about pharmacist disaster roles between September 11, 2001, and September 30, 2011. An initial total of 103 journal articles were available for analysis. Of this pool of articles, 31 were published outside the pharmacy literature, 18 were published prior to September 11, 2001, 7 articles were unavailable electronically, 4 articles represented nonpeer-reviewed literature, 4 were substantively unrelated to the topic of research, and 2 articles were published in a non-English language. Thus, a total of 37 articles were included in the final analysis.
Measurements and Instrumentation Variables were operationalized using the categorization scheme presented by Setlak, and disasters likewise encompassed events classified according to groupings previously mentioned.7 Storms, a category used in the analysis and not previously defined, encompasses literature reports of rainstorms, windstorms, tropical storms, and snowstorms. Each item in the categories was quantified, and the cumulative total was ascribed to the associated category. The role and disaster categories were then compared using descriptive and inferential methods.
Data Analysis
Design and Sample The nature of explaining and characterizing pharmacists’ roles in disaster preparedness and response as reported in the pharmacy literature necessitates an examination of available journal articles. Content analysis, a method of ‘‘transforming qualitative material into quantitative data and consisting primarily of coding and tabulating occurrences of certain forms of content,’’ offers the appropriate unobtrusive study design to measure the occurrences of pharmacists’ roles and the disasters referenced in the literature.10 Data were collected initially to test the coding scheme, which involved counting the occurrences of specific words or phrases such as ‘‘consultant,’’ ‘‘dispensing,’’ ‘‘counseling,’’ ‘‘distribution,’’ ‘‘triage,’’ ‘‘bioterrorism,’’ ‘‘nuclear,’’ ‘‘anthrax,’’ ‘‘weapons of mass destruction,’’ ‘‘hurricane,’’ or ‘‘tornado’’ that describe pharmacists’ roles and disasters. Data coding was performed solely by the lead author using Concordance1 (Harvard University, Cambridge, Massachusetts), a Web-based content analysis software. The units of analysis and observation are journal articles used in the study. Articles were located using tertiary sources such as PubMed, Medline, the Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, sociological sources including socINDEX and Social Work Abstracts, and the table of contents of peer-reviewed pharmacy journals. Because peer-reviewed publications are the primary medium for showcasing frontline research, it is assumed that the current state of pharmacy preparedness can be
Totals from the categories were used both to describe the data and to find differences among the proportions of roles reported and journals reporting the roles. Chi-square analyses were used to determine whether significant differences exist between the proportions of role categories and to determine whether journals significantly differ in the proportion of role categories reported. Data were analyzed for statistical significance (a ¼ .05) using Minitab software (version 15; Minitab, Inc).
Results With exception to response integration roles, only 4 of which were recorded in the article sample, weighted counts of pharmacy roles in all the journals show a decreasing trend in pharmacist role reports beginning with patient management and moving to the pharmaceutical supply and policy coordination categories (Figure 1). Chi-square goodness-of-fit analysis of the weighted counts suggests very significant differences between response integration, patient management, pharmaceutical supply, and policy coordination roles (P < .001, w2 ¼ 71.59). Figure 2 shows pharmacy roles categorized according to journal. Data strongly suggest that role categories are proportioned unequally among the journals sampled (P ¼ .002, w2 ¼ 25.905). Pharmaceutical supply responsibilities are predominant in the American Journal of Health-System Pharmacy
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Table 2. Chronologic Order of and Article Reference for Disasters Appearing in the Pharmacy Literature. Year
Month
Event
Reference
1963 1965 1966 1966 1966 1979 1984 1987
October November March March April N/A N/A N/A
17 17 17 17 17 23,36 13,23,35 16
1989
July
1989 1989 1990 1991 1991 1992 1992 1992 1992 1993 1995 1995 1996 1996 1997 1998
September November N/A January N/A August September N/A N/A N/A N/A April N/A November N/A N/A
1999 2001
February September
2001
October
2001 2002 2003 2004 2005 2005 2008 2008 2008 2008 2009
November N/A March N/A August September February July September N/S N/A
Coliseum explosion in Indianapolis Amory explosion in Iowa Tornado in Jackson, Mississippi Train collision in Montana Tornado in Florida Anthrax release from Sverdlovsk, USSR Salmonella typhimurium release in Dalles, Oregon food stocks Chemical spill of 55% of hydrogen peroxide from ruptured tank of an overturned tractor trailer near Detroit Crash of United Airlines flight 232 at Sioux Gateway Airport, Sioux City, Iowa Hurricane Hugo Tornado in Huntsville, Alabama Aum Shinrikyo anthrax and botulinum toxin attacks Operation desert storm begins Conflict in Yugoslavia Hurricane Andrew Hurricane Iniki Siege of Sarajevo Conflict in Bosnia-Herzegovina World Trade Center bombing, New York City Tokyo subway sarin attack Alfred P. Murrah Federal Building bombing, Oklahoma City, Oklahoma Atlanta Olympic Games bombing Crash of Ethiopian Airlines Boeing 767 in Indian Ocean Anthrax hoax at B’nai B’rith headquarters in Washington, District of Columbia Israel distributes an unknown antibiotic to citizenry in response to Iraq SCUD missile threat Letters containing anthrax delivered to a dental clinic World Trade Center, Pentagon attacked, plane downed in Pennsylvania believed to be flying toward White House Anthrax attacks in Washington, District of Columbia, Florida, New Jersey, and New York Operation Enduring Freedom SARS outbreak in China SARS outbreak in Toronto, Canada Electrical grid failure, North American eastern seaboard Hurricane Katrina Hurricane Rita Snowstorm in Spokane, Washington Hurricane Dolly Hurricane Ike Tornado and flooding in Iowa H1N1 outbreak
18,33 30 18,37 23 18,26,38 39 21 27,37 39 39 23 5,13,23,35,36,40 18,19,23 18 41 23 23 35 3,5,7,11,18,19,24,26,36,42,43,44,45,46 5,7,11,18,26,29,32,36,40,42,43,45,46 26 6 3,6 3 25,31,34,44,47,48 21,31 31,32 49 49 32 46
Abbreviations: N/A, not applicable; SARS, severe acute respiratory syndrome.
but are emphasized to a lesser degree in other journals. Patient management roles, by contrast, are more frequently reported in the Journal of the American Pharmacists Association, Annals of Pharmacotherapy, and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. Although policy coordination and response integration describe potential roles for pharmacists in disasters, they are not emphasized to a great extent in the journal sample. Differences in the weighted counts of natural disasters reported did not reach statistical significance (P ¼ .358, w2 ¼ 0.846). Hurricanes are the predominant natural disaster
recorded (Figure 3). Other natural disasters, including floods, earthquakes, and fires, were not recorded in the sample of articles. Biological disasters also predominate among CBRN disasters (Figure 4) reported in the pharmacy journals, where evidence strongly suggests differences in the proportion of documented CBRN disasters (P < .001, w2 ¼ 70.945).
Discussion Pharmaceutical supply has been the primary focus of pharmacy services since the advent of mass-produced,
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Weighted Counts of Roles Reported in the PharmacyLiterature
354
90 80 70 60 50 40 30 20 10 0
79
55 33
4 Response Integration
Patient Management
Pharmaceutical Supply
Policy Coordination
Roles
Weighted Counts of Role Categories Reported per journal
Figure 1. Weighted counts of roles reported in the pharmacy literature.
35
31
30
Response Integration
27
25
Patient Management
20 20
17 14
15
11
11
11 11 8
10 5
3 3
2
1
0
Policy Coordination
1
0 AJHP
JAPHA
ANN
Pharmaceutical Supply
PHARM
Journals
Weighted Counts Among Pharmacy Journals
Figure 2. Roles categorized according to journals. American Journal of Health-System Pharmacy (AJHP), Journal of the American Pharmacists Association (JAPHA), Annals of Pharmacotherapy (ANN), and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy (PHARM).
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0
4 3
3 AJHP
1
1
1
1
JAPHA PHARM
ND T - Tornadoes
ND H - Hurricane
ND S - Storms
Natural Disasters
Figure 3. Natural disasters categorized according to journal. American Journal of Health-System Pharmacy (AJHP), Journal of the American Pharmacists Association (JAPHA), and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy (PHARM).
standardized, and highly sophisticated pharmaceutical dosage forms and delivery systems. However, the dispensing paradigm of pharmacy service delivery began transitioning to a more patient-centered focus with the introduction of the
pharmaceutical care model by Hepler and Strand.2 Since that time, the profession has increasingly diversified to incorporate specialty practices in almost every area of medical science, including disaster preparedness.
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Pharmacy Journals
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1
PHARM
150
2 ANN
113
3
Nuclear Disaster Radiologic Disaster
JAPHA
18
1
Biologic Disaster
2 2
AJHP
9 0
Chemical Disaster
21 50
100
150
Number of CBRN Disasters Recorded in the Pharmacy Literature
Figure 4. Chemical, biological, radiological, and nuclear (CBRN) disasters categorized according to journal. American Journal of Health-System Pharmacy (AJHP), Journal of the American Pharmacists Association (JAPHA), Annals of Pharmacotherapy (ANN), and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy (PHARM).
The fact that a substantial number of disaster role reports include nonsupply activities is not surprising since disaster preparedness itself represents a pharmacy specialty practice. The plethora of patient management roles, in contrast to the comparatively minimal reports of policy coordination and response integration activities, may reflect the degree to which pharmacists are currently employed. For example, most pharmacists may not be directly involved in routine triage and first-aid activities as emergency medical technicians, nurses, or physicians might be, and policy coordination may be less of a professional interest for those involved in patient management and pharmaceutical supply services. These lesser documented, nontraditional pharmacist activities, however, are supported by national pharmacy organizations such as the American Society of Health System Pharmacists. The organization, for example, encourages pharmacist participation in disaster planning, particularly coordinating institutional pharmaceutical plans with private, local, state, and federal planners. It also recognizes the need for pharmacists to develop first aid, CPR, and basic cardiac life support skills to better integrate with medical responders.11 This analysis, albeit a static, cross-sectional view of the current state of pharmacy’s role in disasters, may reflect the beginning of a rising trend in those areas currently under-reported, namely, in response integration and policy coordination. Although a comparatively high number of patient management reports in Annals of Pharmacotherapy and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy are not unexpected given their clinical orientations, the differences observed in the pharmaceutical supply and patient management categories in the American Journal of Health-System Pharmacy and Journal of the American Pharmacists Association are more interesting. Because the journals represent 2 vast and related sectors of the profession—hospital and community pharmacy—it would not be surprising to find their role categories roughly equally distributed. For example, both journals represent issues concerning pharmaceutical supply and clinical management. However, the preponderance of reports in the
Journal of the American Pharmacists Association related to vaccinations and individual and group counseling may have tipped the proverbial balance toward a more clinical orientation. Hurricanes, storms, and tornadoes are the most frequently reported natural disasters found in the pharmacy literature. This finding corresponds well with the types of disasters that led to Presidential Disaster Declarations between 1964 and 2007, approximately 67% of which were severe storms and hurricanes.12 It is possible that the media attention given to hurricanes Katrina and Rita may have affected the growth of practice reports describing pharmacy response in these types of natural disasters. CBRN threats have been given significant attention by the medical community since the September 11 attacks on the United States. Biological terrorism has generally been the expected mode of attack for various reasons. For instance, casualties resulting from the release of kilogram of anthrax spores can approximate the number of casualties expected from 1 kiloton of nuclear blast. Biological attacks are also insidious, require widespread patient care, and could result in extensive fatalities.13 Although chemical disasters, too, are also anticipated, according to our data, the expectation is likely less than that of biological disasters. The chlorine gas and methyl isocyanate releases in Graniteville, South Carolina, and Bhopal, India, respectively, provide prescient reminders of the need for preparation for catastrophic chemical events. Nuclear and radiological disasters, however, may represent the soft underbelly of disaster medicine. Our data show that most of the articles sampled refer predominantly to biological and chemical disasters and infrequently to radiological and nuclear disasters. The data corroborate well with statistics reported by the Council of State and Territorial Epidemiologists which indicate that as much as 85% of the states have an insufficient capability to respond to a radiation incident. One important question that may be considered is, ‘‘why are there virtually no references in pharmacy literature to the health consequences of nuclear disaster?’’ It may, in part, be due to the
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notion that nuclear disasters are so terrible that nothing can be done.14 It may also be due to the fact that a nuclear disaster has not occurred recently within the United States. Another interesting explanation holds that many in the medical and public health communities consider nuclear terrorism unlikely in comparison to chemical or biological terrorism. However, as Dallas and Burkle discussed, this notion may reflect mass denial, where many ‘‘attempt to reject conscious knowledge of unacceptable events.’’ 15 When considering Iran’s unfaltering pursuit of nuclear weapons, the conventional understanding of Israel’s vast nuclear weapons capability, the failed state of North Korea which uses threats as its only diplomatic leverage, and the ubiquitous religious extremism in the Middle East, the likelihood of nuclear disaster in the coming years is much greater than the literature may indicate.15 Fortunately, this neglect of nuclear and radiological preparedness, which is also a significant concern of the medical community, is now being addressed in the hope that efforts will ‘‘greatly enhance our ability to mitigate this impact so that we can realistically think from a population perspective of mutually assured survival.’’14
Limitations Peer-reviewed literature is an important means of communicating key information to the profession. Nonpeer-reviewed literature, however, is also a significant method of communicating with both pharmacists and nonpharmacist readers. Although this analysis excluded, in addition to nonpeer-reviewed pharmacy literature, other important sources of information including peer-reviewed and nonpeer-reviewed medical, nursing, and public health literature related to disasters including these various types of articles would enhance the robustness of the results. Another particularly relevant limitation is the exclusion of nonelectronically available journal articles. Seven articles were excluded for this reason which would otherwise have been an ample source of data. Perhaps the most significant sources of information not used in this analysis are peer-reviewed and nonpeer-reviewed journal articles published prior to September 11, 2001. The present study aimed to determine the current level of professional preparedness and thus limited the scope of articles to those published within the past decade. Lessons from history, however, should not be neglected, and further research should examine this source of information for guidance in future disasterrelated planning. Boolean-type functions available in the Concordance software package were not used to define relationships with words or groups of words; thus, the results may only approximate the true number of references to pharmacist roles and disasters in the literature.
Conclusion Data suggest that pharmacists may be prepared to respond to hurricanes and biological and chemical disasters in
pharmaceutical supply and patient management roles. However, it also underscores the need for greater attentiveness to response integration and policy coordination responsibilities and readiness in nuclear and radiological disaster preparedness as well. The implications of the research may be far-reaching. As the pharmacy profession develops its various roles in disaster management, the entire medical response will benefit. Local, state, and federal planners will be able to allocate scarce human resources more effectively when the pharmacy response capabilities are well developed. Ultimately, the ability of terrorists to disrupt society will decrease, and the response to natural disasters will be greatly augmented by the multiple proficiencies the profession continues to develop. This analysis also reveals the liabilities of the profession’s disaster capability, a vulnerability that could be exploited either intentionally through terrorism or unintentionally through natural events. The lack of recorded efforts in policy coordination and response integration activities may impede the development and execution of a robust pharmacy response. Pharmacy journals may consider encouraging future practice reports and research articles highlighting these important roles as well as efforts to prepare health systems for the effects of nuclear and radiological disasters. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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46.
47. 48. 49.
contaminated mail. Am J Health Syst Pharm. 2002;59(12): 1189-1192. Guynn JB Jr . Disaster imminent—Hurricane Hugo. Hosp Pharm. 1990;25(4):325-328. Traynor K. Response teams need pharmacists. Am J Health Syst Pharm. 2008;65(10):904. Terriff CM, Newton S. Pharmacist role in emergency preparedness. J Am Pharm Assoc. 2008;48(6):702,707. Carda E, Harcum J, Olthoff C. Mass casualty: a hospital pharmacist’s call to action. Hosp Pharm. 1989;24(9):697-699. Traynor K. Pharmacy, public health intersect in Alabama disaster plans. Am J Health Syst Pharm. 2007;64(19):1998-1999. Terriff CM, Tee AM. Citywide pharmaceutical preparation for bioterrorism. Am J Health Syst Pharm. 2001;58(3):233-237. Idemyor V, Smith SW. Biologic warfare—a growing healthcare concern. Ann Pharmacother. 2002;36(7-8):1282-1286. Cramer RL, Weeks KG. Pharmacy disaster emergency: the Huntsville tornado. Hosp Pharm. 1990;25(6):523-526. Robinson RF, Nahata MC. Management of botulism. Ann Pharmacother. 2003;37(1):127-131. Bussieres JF, St-Arnaud C, Schunck C, et al. The role of the pharmacist in humanitarian aid in Bosnia-Herzegovina: the experience of Pharmaciens Sans Frontieres. Ann Pharmacother. 2000;34(1): 112-118. Burda AM, Sigg T. Pharmacy preparedness for incidents involving weapons of mass destruction. Am J Health Syst Pharm. 2001; 58(23):2274-2284. Berod T, Chan-ou-Teung F. Pharmacist’s role in rescue efforts after plane crash in Indian Ocean. Am J Health Syst Pharm. 1997;54(9):1110. Pedersen CA, Canaday BR, Ellis WM, et al. Pharmacists’ opinions regarding level of involvement in emergency preparedness and response. J Am Pharm Assoc. 2003;43(6):694-701. Stergachis A, Lander R. Promoting the pharmacist’s role in public health. J Am Pharm Assoc. 2006;46(3):311-314. Feret B, Bratberg J. Pharmacist-based intervention to prepare residents of assisted-living facilities for emergencies. J Am Pharm Assoc. 2008;48(6):780-783. Lee JJ, Johnson SJ, Sohmer MJ. Guide for mass prophylaxis of hospital employees in preparation for a bioterrorist attack. Am J Health Syst Pharm. 2009;66(6):570-575. Bhavsar TR, Kim HJ, Yu Y. Roles and contributions of pharmacists in regulatory affairs at the centers for disease control and prevention for public health emergency preparedness and response. J Am Pharm Assoc. 2010;50(2):165-168. Bratberg J. Hurricane Katrina: pharmacists making a difference. J Am Pharm Assoc. 2005;45(6):654-658. Traynor K. Pharmacists play vital roles in Katrina response. Am J Health Syst Pharm. 2005;62(21):2202-2216. Lynx DH. Preparing for forecastable disasters. Am J Health Syst Pharm. 2009;66(17):1578-1581.
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Pharmacists’ Roles in Post-September 11th Disasters: A Content Analysis of Pharmacy Literature
Journal of Pharmacy Practice 2014, Vol. 27(4) 350-357 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190013507081 jpp.sagepub.com
Heath Ford, PharmD, PhD, CGP1, Trina von Waldner, PharmD2, and Matthew Perri III, RPh, PhD3
Abstract Purpose: To characterize the roles pharmacists have assumed in disasters and clarify the types of roles and disasters that may be less well-documented in the pharmacy literature. Methods: This research examines how balanced or equally proportioned role categories are in the pharmacy literature, whether pharmacy journals differ in the proportion of role categories reported, and whether journals significantly differ in the proportion of reported chemical, biological, radiological, nuclear (CBRN), and natural disasters. Data coding was performed solely by the lead author using Concordance (Harvard University, Cambridge, Massachusetts), a Web-based content analysis software, and Minitab1 (version 15; Minitab, Inc; State College, Pennsylvania) for descriptive and inferential statistical analysis. Pharmacy journals publishing at least 2 articles about pharmacist disaster roles from September 11, 2001 to September 30, 2011 were used in the study and were available electronically. Results: Chi-square analyses reveal significant differences in the weighted counts of roles, roles categorized by journal, and CBRN disasters categorized by journal. Conclusions: Data suggest that pharmacists may be prepared to respond to hurricanes and biological and chemical disasters in pharmaceutical supply and patient management roles. Future research should highlight efforts to prepare health systems for the effects of nuclear, radiological, and chemical disasters. Keywords disaster management, disaster preparedness, natural disasters, terrorism, pharmacist roles
Introduction and Purpose Statement The role of the pharmacist in disaster preparedness and response has become increasingly important since the terrorist attacks on the World Trade Center and Pentagon. Pharmacists have traditionally managed the nation’s drug supply by dispensing prescription medications to patients presenting with a physician’s order, but while this role continues as the mainstay of most pharmacy practices, pharmacists’ skills have developed well beyond those traditionally described.1 With the advent of the pharmaceutical care paradigm introduced by Hepler and Strand in the early 1990s, pharmacists have assumed more patient-oriented roles in their daily activities, moving beyond traditional dispensing duties and actively assuming the responsibilities of a primary care provider.2 Some of these activities include counseling patients regarding medication use, managing oral and intravenous medications, consulting with prescribers regarding optimal pharmacotherapy and parenteral nutrition, and monitoring patients for drug-related problems. Practice activities have embraced the ideals of ensuring proper use of medications and mitigating human suffering. Austin and colleagues, for example, note that in times of crisis, local pharmacies become crucial to maintaining public health care services, and pharmacists, the health professional group
most accessible to the public, assume responsibilities beyond their traditional scope of practice.3 Previous research articles, including Braucher’s description of pharmacist roles in relief efforts after a simulated nuclear detonation, are particularly relevant to a post-September 11th era and certify the importance of pharmacist participation in disaster preparedness and response, especially when few health care providers are expected to survive the initial events.4 Disaster preparedness and response are specific domains in which pharmacists can provide valuable expertise to improve patient outcomes and promote appropriate medication use.
1 Department of Pharmacy Practice, South College School of Pharmacy, Knoxville, TN, USA 2 Division of Nontraditional Education and Outreach, University of Georgia College of Pharmacy, Athens, GA, USA 3 Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
Corresponding Author: Heath Ford, Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 231 R.C. Wilson Pharmacy Building, Athens, GA 30602, USA. Email: [email protected]
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Although resource-depleting disasters present scenarios where pharmacists assume tasks traditionally belonging to other disciplines, these scenarios have not been sufficiently elucidated in the literature.3 Multiple reports describe the utility of traditional and expanded activities of pharmacy practice in a variety of natural and man-made disasters, with the pool of published articles continuing to increase.5-48 As Cohen notes, however, little attention has been given to characterizing the roles of pharmacists in disasters although the importance of pharmacists’ involvement is widely acknowledged.5 In fact, no report to date has been published that both characterizes the roles pharmacists have assumed in disasters and clarifies the types of roles that may be less well-documented in the pharmacy literature. Consequently, various roles may be understated, pharmacy response to disasters may be less well developed, and the capability of terrorists to do harm may ultimately be increased. When considering the reports describing how pharmacists have responded to disasters, questions arise: which roles and disasters have the most literature support and do journals show tendencies in reporting particular roles and disasters? One would assume that traditional, routine roles such as dispensing medications and counseling patients would be 2 that should be well developed in the pharmacy literature, but patient-centered, hands-on functions such as providing direct aid to casualties at the site of disaster may not be as proportionately represented. Journals may also significantly record more of specific types of pharmacy roles. For example, the American Pharmacists Association is a major advocate of pharmacists as immunization providers and devotes a portion of their journal and professional Web site to help pharmacists attain certification and maintain immunization practice standards. It is not clear, however, whether the Journal of the American Pharmacists Association reports immunization practices as a disaster response function more than other pharmacy journals. Similarly, the American Journal of Health-System Pharmacy may also limit their reports of role descriptions to those that would most likely interest hospital pharmacists (eg, developing medication guides, managing emergency formularies, providing poison information services, etc). Pharmacy journals may show tendencies in reporting particular disaster preparedness and response functions and thus perceive certain events as more relevant than others. This could unexpectedly present unique challenges to the provision of pharmacy services if certain disasters are not adequately addressed in the literature. Chemical, biological, radiological, nuclear (CBRN) and natural disasters reported in pharmacy literature may also be unequally proportioned. For example, widespread disasters caused by detonation of a small nuclear device, widespread bioterrorism, collapse of multiple city skyscrapers, or due to natural causes may not be proportionately recorded in the literature and thus represent areas of pharmacy preparedness that are inadequately developed. Thus, the purpose of this research is to describe pharmacists’ disaster preparedness and response roles according to published reports in pharmacy literature and to clarify the types of disasters that have been reported. To this end, 3 primary
questions will be addressed. (1) How balanced or equally proportioned are role categories in the pharmacy literature? (2) Do journals significantly differ in the proportion of role categories reported? (3) Do journals significantly differ in the proportion of reported natural and CBRN disasters?
Methods Role Categorization Pharmacists’ roles in disasters have been categorized in at least 3 reports in the pharmacy literature.6-8 Pincock and colleagues present a disaster-readiness model to better prepare pharmacists and disasters planners for future contingencies. A second categorization elucidated by Chin and colleagues is noteworthy for the identification of 5 categories of pharmacy functions: drug information, direct patient care, pharmacy operations, collaboration and communication, and personnel management. However, in terms of characterizing and explaining pharmacists’ roles in disasters, perhaps the most carefully defined categorization of pharmacists’ functions is set forth by Setlak who identifies 4 main types: response integration, patient management, pharmaceutical supply, and policy coordination. Response integration describes pharmacists integrating into the casualty response by triaging patients alongside physicians and nurses and administering first aid and cardiopulmonary resuscitation (CPR) as experience and training allow. Patient management, the second category, involves patient-centered approaches to managing medication therapy outcomes. Pharmaceutical supply, the third category, describes the logistics of providing medications to large numbers of patients, and the last category describes the need for pharmacists to help coordinate disaster policy to eliminate duplicate therapies in emergency formularies, streamline paperwork to avoid duplicative forms, and generally apply drug expertise in decision making.7 This article organizes the broad array of pharmacy literature reports of pharmacists’ disaster functions according to the Setlak categorization.
Disasters in the Pharmacy Literature Numerous references to disasters have appeared in the pharmacy literature since as early as the 1960s. Two classifications—natural disasters and terrorism—will be used to classify disaster types. Table 1 describes the disaster classification scheme used in this analysis. Natural disasters may include tornadoes, fires, earthquakes, floods, or any man-made accident. Terrorism includes CBRN terrorism or use of any ‘‘violent or threatening means to intimidate or coerce, especially for political purposes.’’9 Table 2 displays the chronologic order of the disasters with journal articles that give reference. The disaster genre of pharmacy literature beginning in the early 1960s to the 1980s exclusively reflects responses to natural disasters. The 1980s begin to reference terrorism, with the quantity of literature citations growing substantially in the 1990s. Although the 2000s are dominated primarily by articles citing natural disasters, the
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Table 1. Disaster Classification Scheme. Natural Disasters Tornadoes Fires Earthquakes Floods Hurricanes Storms (rainstorms, windstorms, tropical storms, and snowstorms) Manmade accidentsa (train, car, and plane crashes) CBRN disasters (including terrorism) Chemical (any chemical agent as well as bombs, explosions, and explosives) Biological (any biologic agent as well as pandemic influenza) Radiological (including ‘‘dirty bombs’’) Nuclear Abbreviation: CBRN, chemical, biological, radiological, nuclear. a Excludes CBRN disasters.
2 main acts of terrorism frequently referenced by articles in the pharmacy literature are the September 11, 2001 attacks on the World Trade Center and Pentagon as well as the October 2001 anthrax attacks in Washington, District of Columbia, Florida, New Jersey, and New York. Particularly noteworthy is the prevalence of terrorism reports from 1993 to 2001, with natural disasters dominating literature before and after this period.
elucidated from an analysis of peer-reviewed pharmacy publications. As such, peer-reviewed pharmacy journals used in the study were available electronically and published at least 2 articles about pharmacist disaster roles between September 11, 2001, and September 30, 2011. An initial total of 103 journal articles were available for analysis. Of this pool of articles, 31 were published outside the pharmacy literature, 18 were published prior to September 11, 2001, 7 articles were unavailable electronically, 4 articles represented nonpeer-reviewed literature, 4 were substantively unrelated to the topic of research, and 2 articles were published in a non-English language. Thus, a total of 37 articles were included in the final analysis.
Measurements and Instrumentation Variables were operationalized using the categorization scheme presented by Setlak, and disasters likewise encompassed events classified according to groupings previously mentioned.7 Storms, a category used in the analysis and not previously defined, encompasses literature reports of rainstorms, windstorms, tropical storms, and snowstorms. Each item in the categories was quantified, and the cumulative total was ascribed to the associated category. The role and disaster categories were then compared using descriptive and inferential methods.
Data Analysis
Design and Sample The nature of explaining and characterizing pharmacists’ roles in disaster preparedness and response as reported in the pharmacy literature necessitates an examination of available journal articles. Content analysis, a method of ‘‘transforming qualitative material into quantitative data and consisting primarily of coding and tabulating occurrences of certain forms of content,’’ offers the appropriate unobtrusive study design to measure the occurrences of pharmacists’ roles and the disasters referenced in the literature.10 Data were collected initially to test the coding scheme, which involved counting the occurrences of specific words or phrases such as ‘‘consultant,’’ ‘‘dispensing,’’ ‘‘counseling,’’ ‘‘distribution,’’ ‘‘triage,’’ ‘‘bioterrorism,’’ ‘‘nuclear,’’ ‘‘anthrax,’’ ‘‘weapons of mass destruction,’’ ‘‘hurricane,’’ or ‘‘tornado’’ that describe pharmacists’ roles and disasters. Data coding was performed solely by the lead author using Concordance1 (Harvard University, Cambridge, Massachusetts), a Web-based content analysis software. The units of analysis and observation are journal articles used in the study. Articles were located using tertiary sources such as PubMed, Medline, the Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, sociological sources including socINDEX and Social Work Abstracts, and the table of contents of peer-reviewed pharmacy journals. Because peer-reviewed publications are the primary medium for showcasing frontline research, it is assumed that the current state of pharmacy preparedness can be
Totals from the categories were used both to describe the data and to find differences among the proportions of roles reported and journals reporting the roles. Chi-square analyses were used to determine whether significant differences exist between the proportions of role categories and to determine whether journals significantly differ in the proportion of role categories reported. Data were analyzed for statistical significance (a ¼ .05) using Minitab software (version 15; Minitab, Inc).
Results With exception to response integration roles, only 4 of which were recorded in the article sample, weighted counts of pharmacy roles in all the journals show a decreasing trend in pharmacist role reports beginning with patient management and moving to the pharmaceutical supply and policy coordination categories (Figure 1). Chi-square goodness-of-fit analysis of the weighted counts suggests very significant differences between response integration, patient management, pharmaceutical supply, and policy coordination roles (P < .001, w2 ¼ 71.59). Figure 2 shows pharmacy roles categorized according to journal. Data strongly suggest that role categories are proportioned unequally among the journals sampled (P ¼ .002, w2 ¼ 25.905). Pharmaceutical supply responsibilities are predominant in the American Journal of Health-System Pharmacy
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Table 2. Chronologic Order of and Article Reference for Disasters Appearing in the Pharmacy Literature. Year
Month
Event
Reference
1963 1965 1966 1966 1966 1979 1984 1987
October November March March April N/A N/A N/A
17 17 17 17 17 23,36 13,23,35 16
1989
July
1989 1989 1990 1991 1991 1992 1992 1992 1992 1993 1995 1995 1996 1996 1997 1998
September November N/A January N/A August September N/A N/A N/A N/A April N/A November N/A N/A
1999 2001
February September
2001
October
2001 2002 2003 2004 2005 2005 2008 2008 2008 2008 2009
November N/A March N/A August September February July September N/S N/A
Coliseum explosion in Indianapolis Amory explosion in Iowa Tornado in Jackson, Mississippi Train collision in Montana Tornado in Florida Anthrax release from Sverdlovsk, USSR Salmonella typhimurium release in Dalles, Oregon food stocks Chemical spill of 55% of hydrogen peroxide from ruptured tank of an overturned tractor trailer near Detroit Crash of United Airlines flight 232 at Sioux Gateway Airport, Sioux City, Iowa Hurricane Hugo Tornado in Huntsville, Alabama Aum Shinrikyo anthrax and botulinum toxin attacks Operation desert storm begins Conflict in Yugoslavia Hurricane Andrew Hurricane Iniki Siege of Sarajevo Conflict in Bosnia-Herzegovina World Trade Center bombing, New York City Tokyo subway sarin attack Alfred P. Murrah Federal Building bombing, Oklahoma City, Oklahoma Atlanta Olympic Games bombing Crash of Ethiopian Airlines Boeing 767 in Indian Ocean Anthrax hoax at B’nai B’rith headquarters in Washington, District of Columbia Israel distributes an unknown antibiotic to citizenry in response to Iraq SCUD missile threat Letters containing anthrax delivered to a dental clinic World Trade Center, Pentagon attacked, plane downed in Pennsylvania believed to be flying toward White House Anthrax attacks in Washington, District of Columbia, Florida, New Jersey, and New York Operation Enduring Freedom SARS outbreak in China SARS outbreak in Toronto, Canada Electrical grid failure, North American eastern seaboard Hurricane Katrina Hurricane Rita Snowstorm in Spokane, Washington Hurricane Dolly Hurricane Ike Tornado and flooding in Iowa H1N1 outbreak
18,33 30 18,37 23 18,26,38 39 21 27,37 39 39 23 5,13,23,35,36,40 18,19,23 18 41 23 23 35 3,5,7,11,18,19,24,26,36,42,43,44,45,46 5,7,11,18,26,29,32,36,40,42,43,45,46 26 6 3,6 3 25,31,34,44,47,48 21,31 31,32 49 49 32 46
Abbreviations: N/A, not applicable; SARS, severe acute respiratory syndrome.
but are emphasized to a lesser degree in other journals. Patient management roles, by contrast, are more frequently reported in the Journal of the American Pharmacists Association, Annals of Pharmacotherapy, and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. Although policy coordination and response integration describe potential roles for pharmacists in disasters, they are not emphasized to a great extent in the journal sample. Differences in the weighted counts of natural disasters reported did not reach statistical significance (P ¼ .358, w2 ¼ 0.846). Hurricanes are the predominant natural disaster
recorded (Figure 3). Other natural disasters, including floods, earthquakes, and fires, were not recorded in the sample of articles. Biological disasters also predominate among CBRN disasters (Figure 4) reported in the pharmacy journals, where evidence strongly suggests differences in the proportion of documented CBRN disasters (P < .001, w2 ¼ 70.945).
Discussion Pharmaceutical supply has been the primary focus of pharmacy services since the advent of mass-produced,
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Weighted Counts of Roles Reported in the PharmacyLiterature
354
90 80 70 60 50 40 30 20 10 0
79
55 33
4 Response Integration
Patient Management
Pharmaceutical Supply
Policy Coordination
Roles
Weighted Counts of Role Categories Reported per journal
Figure 1. Weighted counts of roles reported in the pharmacy literature.
35
31
30
Response Integration
27
25
Patient Management
20 20
17 14
15
11
11
11 11 8
10 5
3 3
2
1
0
Policy Coordination
1
0 AJHP
JAPHA
ANN
Pharmaceutical Supply
PHARM
Journals
Weighted Counts Among Pharmacy Journals
Figure 2. Roles categorized according to journals. American Journal of Health-System Pharmacy (AJHP), Journal of the American Pharmacists Association (JAPHA), Annals of Pharmacotherapy (ANN), and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy (PHARM).
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0
4 3
3 AJHP
1
1
1
1
JAPHA PHARM
ND T - Tornadoes
ND H - Hurricane
ND S - Storms
Natural Disasters
Figure 3. Natural disasters categorized according to journal. American Journal of Health-System Pharmacy (AJHP), Journal of the American Pharmacists Association (JAPHA), and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy (PHARM).
standardized, and highly sophisticated pharmaceutical dosage forms and delivery systems. However, the dispensing paradigm of pharmacy service delivery began transitioning to a more patient-centered focus with the introduction of the
pharmaceutical care model by Hepler and Strand.2 Since that time, the profession has increasingly diversified to incorporate specialty practices in almost every area of medical science, including disaster preparedness.
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Pharmacy Journals
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1
PHARM
150
2 ANN
113
3
Nuclear Disaster Radiologic Disaster
JAPHA
18
1
Biologic Disaster
2 2
AJHP
9 0
Chemical Disaster
21 50
100
150
Number of CBRN Disasters Recorded in the Pharmacy Literature
Figure 4. Chemical, biological, radiological, and nuclear (CBRN) disasters categorized according to journal. American Journal of Health-System Pharmacy (AJHP), Journal of the American Pharmacists Association (JAPHA), Annals of Pharmacotherapy (ANN), and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy (PHARM).
The fact that a substantial number of disaster role reports include nonsupply activities is not surprising since disaster preparedness itself represents a pharmacy specialty practice. The plethora of patient management roles, in contrast to the comparatively minimal reports of policy coordination and response integration activities, may reflect the degree to which pharmacists are currently employed. For example, most pharmacists may not be directly involved in routine triage and first-aid activities as emergency medical technicians, nurses, or physicians might be, and policy coordination may be less of a professional interest for those involved in patient management and pharmaceutical supply services. These lesser documented, nontraditional pharmacist activities, however, are supported by national pharmacy organizations such as the American Society of Health System Pharmacists. The organization, for example, encourages pharmacist participation in disaster planning, particularly coordinating institutional pharmaceutical plans with private, local, state, and federal planners. It also recognizes the need for pharmacists to develop first aid, CPR, and basic cardiac life support skills to better integrate with medical responders.11 This analysis, albeit a static, cross-sectional view of the current state of pharmacy’s role in disasters, may reflect the beginning of a rising trend in those areas currently under-reported, namely, in response integration and policy coordination. Although a comparatively high number of patient management reports in Annals of Pharmacotherapy and Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy are not unexpected given their clinical orientations, the differences observed in the pharmaceutical supply and patient management categories in the American Journal of Health-System Pharmacy and Journal of the American Pharmacists Association are more interesting. Because the journals represent 2 vast and related sectors of the profession—hospital and community pharmacy—it would not be surprising to find their role categories roughly equally distributed. For example, both journals represent issues concerning pharmaceutical supply and clinical management. However, the preponderance of reports in the
Journal of the American Pharmacists Association related to vaccinations and individual and group counseling may have tipped the proverbial balance toward a more clinical orientation. Hurricanes, storms, and tornadoes are the most frequently reported natural disasters found in the pharmacy literature. This finding corresponds well with the types of disasters that led to Presidential Disaster Declarations between 1964 and 2007, approximately 67% of which were severe storms and hurricanes.12 It is possible that the media attention given to hurricanes Katrina and Rita may have affected the growth of practice reports describing pharmacy response in these types of natural disasters. CBRN threats have been given significant attention by the medical community since the September 11 attacks on the United States. Biological terrorism has generally been the expected mode of attack for various reasons. For instance, casualties resulting from the release of kilogram of anthrax spores can approximate the number of casualties expected from 1 kiloton of nuclear blast. Biological attacks are also insidious, require widespread patient care, and could result in extensive fatalities.13 Although chemical disasters, too, are also anticipated, according to our data, the expectation is likely less than that of biological disasters. The chlorine gas and methyl isocyanate releases in Graniteville, South Carolina, and Bhopal, India, respectively, provide prescient reminders of the need for preparation for catastrophic chemical events. Nuclear and radiological disasters, however, may represent the soft underbelly of disaster medicine. Our data show that most of the articles sampled refer predominantly to biological and chemical disasters and infrequently to radiological and nuclear disasters. The data corroborate well with statistics reported by the Council of State and Territorial Epidemiologists which indicate that as much as 85% of the states have an insufficient capability to respond to a radiation incident. One important question that may be considered is, ‘‘why are there virtually no references in pharmacy literature to the health consequences of nuclear disaster?’’ It may, in part, be due to the
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notion that nuclear disasters are so terrible that nothing can be done.14 It may also be due to the fact that a nuclear disaster has not occurred recently within the United States. Another interesting explanation holds that many in the medical and public health communities consider nuclear terrorism unlikely in comparison to chemical or biological terrorism. However, as Dallas and Burkle discussed, this notion may reflect mass denial, where many ‘‘attempt to reject conscious knowledge of unacceptable events.’’ 15 When considering Iran’s unfaltering pursuit of nuclear weapons, the conventional understanding of Israel’s vast nuclear weapons capability, the failed state of North Korea which uses threats as its only diplomatic leverage, and the ubiquitous religious extremism in the Middle East, the likelihood of nuclear disaster in the coming years is much greater than the literature may indicate.15 Fortunately, this neglect of nuclear and radiological preparedness, which is also a significant concern of the medical community, is now being addressed in the hope that efforts will ‘‘greatly enhance our ability to mitigate this impact so that we can realistically think from a population perspective of mutually assured survival.’’14
Limitations Peer-reviewed literature is an important means of communicating key information to the profession. Nonpeer-reviewed literature, however, is also a significant method of communicating with both pharmacists and nonpharmacist readers. Although this analysis excluded, in addition to nonpeer-reviewed pharmacy literature, other important sources of information including peer-reviewed and nonpeer-reviewed medical, nursing, and public health literature related to disasters including these various types of articles would enhance the robustness of the results. Another particularly relevant limitation is the exclusion of nonelectronically available journal articles. Seven articles were excluded for this reason which would otherwise have been an ample source of data. Perhaps the most significant sources of information not used in this analysis are peer-reviewed and nonpeer-reviewed journal articles published prior to September 11, 2001. The present study aimed to determine the current level of professional preparedness and thus limited the scope of articles to those published within the past decade. Lessons from history, however, should not be neglected, and further research should examine this source of information for guidance in future disasterrelated planning. Boolean-type functions available in the Concordance software package were not used to define relationships with words or groups of words; thus, the results may only approximate the true number of references to pharmacist roles and disasters in the literature.
Conclusion Data suggest that pharmacists may be prepared to respond to hurricanes and biological and chemical disasters in
pharmaceutical supply and patient management roles. However, it also underscores the need for greater attentiveness to response integration and policy coordination responsibilities and readiness in nuclear and radiological disaster preparedness as well. The implications of the research may be far-reaching. As the pharmacy profession develops its various roles in disaster management, the entire medical response will benefit. Local, state, and federal planners will be able to allocate scarce human resources more effectively when the pharmacy response capabilities are well developed. Ultimately, the ability of terrorists to disrupt society will decrease, and the response to natural disasters will be greatly augmented by the multiple proficiencies the profession continues to develop. This analysis also reveals the liabilities of the profession’s disaster capability, a vulnerability that could be exploited either intentionally through terrorism or unintentionally through natural events. The lack of recorded efforts in policy coordination and response integration activities may impede the development and execution of a robust pharmacy response. Pharmacy journals may consider encouraging future practice reports and research articles highlighting these important roles as well as efforts to prepare health systems for the effects of nuclear and radiological disasters. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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